More Like This

Preview

Let's return to the opening exchange between Lotta (Ms. A) and the therapist. Does Lotta's behavior fit the working definition of manipulativity? To some extent, yes. She seems to have exaggerated her pain in order to get the therapist to pay her a visit. She wasn't particularly indirect, though. The discussion that the authors provide of the case raises the question whether the researchers are reading too much into the initial encounter. As I argued above, research suggests that BPD patients are perceived from the outset to be difficult and manipulative and that carers dislike such patients...

Let's return to the opening exchange between Lotta (Ms. A) and the therapist. Does Lotta's behavior fit the working definition of manipulativity? To some extent, yes. She seems to have exaggerated her pain in order to get the therapist to pay her a visit. She wasn't particularly indirect, though. The discussion that the authors provide of the case raises the question whether the researchers are reading too much into the initial encounter. As I argued above, research suggests that BPD patients are perceived from the outset to be difficult and manipulative and that carers dislike such patients because they are not compliant and cooperative. The worry is that Lotta and the therapist are caught up in this dynamic. Another reading of the encounter is that Lotta is taking initiative to begin shaping the therapeutic relationship because she is anxious about it and does not want to feel that it is out of her control. In doing so, she draws upon not only dramatic ability (‘You could be dying before you got any help around here!’), but also humor (‘You must be either very good or very crazy to have taken me on’) and directness (‘By the way, I hate being called Ms. A.’). It does seem that Lotta is not following social norms for behavior in clinical encounters. Attempting to joke or asking to be called by her first name may be inappropriate in this setting, especially given the emergency call. But it is too quick to decide that ‘[a]lready in this initial interaction with Lotta's therapist-to-be, harbingers of the therapeutic challenges are evident’ (Wheelis and Gunderson 1998). Inappropriateness in behavior suggests social ineptness, not necessarily dysfunction. And inappropriate behavior is sometimes the outcome when someone is challenging conventions and norms that are subjugating. Perhaps Lotta is actively resisting (in the political sense) the patient role as subservient, compliant, and subjugated. All this behavior could turn out to be dysfunctional for Lotta, but one encounter is insufficient to assess her. In order to know whether Lotta is dispositionally and pathologically manipulative, more time in interactions with her is needed, more context needs to be developed, and more attention to clinicians’ perceptions and assumptions needs to be paid.

The question I have been addressing is whether clinicians are justified in taking a pejorative and judgmental stance toward BPD patients. While a violation of norms for relationship might provide an explanation of why clinicians react negatively to BPD patients, it doesn't provide warrant for sweeping labels of manipulativity or the negative attitudes that are entailed. Such attitudes do not satisfy therapeutic and moral norms that clinicians are expected to follow: namely, that clinicians need to develop empathy for their patients’ suffering and distress. When clinicians view patients’ primary character as morally objectionable, it's difficult for clinicians to feel empathy and for patients to either receive or elicit it.

Clarity and carefulness in applying the term ‘manipulation’ will aid clinicians in intercepting negative perceptions, a necessary correlate to being empathetic. BPD patients are suffering and need responses from clinicians that do not exacerbate their distress, and the pervasive attribution of pejorative and blaming manipulativity does not further their healing process.